US - CDC reports potential Ebola exposure in Atlanta lab

[sharon sanders]

CDC reports potential Ebola exposure in Atlanta lab

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Experiments with deadly viruses such as Ebola have to be performed in biosafety level or BSL-4 laboratories, for the highest level on containment. (Tim Brakemeier/AFP/Getty Images)

By Lena H. Sun and Joel Achenbach December 24 at 4:37 PM
One scientist may have been exposed to the Ebola virus and as many as a dozen others are being assessed for potential exposure at a lab of the Centers for Disease Control and Prevention in Atlanta, agency officials said Wednesday.

more...

http://www.washingtonpost.com/nation...91419455093730

 

[sharon sanders]

Where did they say this? Why didn't we get a notice? We are on the CDC media list. This announcement is not on the CDC site as far as I know.

 

[sharon sanders]

Please see:

US CDC Influenza Lab Closed After H5N1 Accidently Sent to Another Government Laboratory 6 Weeks Ago, Plus Moratorium on Movement of All Biological Materials from BSL-3 & 4 labs - July 11, 2014 Media release


link

 

[Pathfinder]

[h=2]Lab Safety[/h] Media Statements

• 12/24/2014: Lab Safety Report on Ebola Virus Transfer

Lab Safety Report on Ebola Virus Transfer

The Centers for Disease Control and Prevention is reporting today that a small amount of material from an Ebola virus experiment that was securely transported from a Select-Agent-approved BSL-4 lab to a Select-Agent-approved BSL-2 lab may have contained live virus. The material was on a sealed plate but should not have been moved into the BSL-2 laboratory. We cannot rule out possible exposure of the one laboratory technician who worked with the material in the BSL-2 laboratory.

There was no possible exposure outside the secure laboratory at CDC and no exposure or risk to the public. The event was discovered by the laboratory scientists yesterday, December 23, and reported to leadership within an hour of the discovery.

The event is under internal investigation by CDC, was reported to Secretary of Health and Human Services Sylvia Burwell, and reporting to the internal and national Select Agent Programs has been initiated. CDC will provide a report on the event when the investigation concludes. The BSL-2 laboratory area had already been decontaminated and the material destroyed as a routine procedure before the error was identified. The laboratory was decontaminated for a second time, and is now closed and transfers from the BSL-4 lab have been stopped while the review is taking place.

"I am troubled by this incident in our Ebola research laboratory in Atlanta," said CDC Director Tom Frieden, M.D., M.P.H. "We are monitoring the health of one technician who could possibly have been exposed and I have directed that there be a full review of every aspect of the incident and that CDC take all necessary measures. Thousands of laboratory scientists in more than 150 labs throughout CDC have taken extraordinary steps in recent months to improve safety. No risk to staff is acceptable, and our efforts to improve lab safety are essential -- the safety of our employees is our highest priority."

CDC will continue to provide support during the Ebola epidemic through its research and diagnostic lab work. Skilled lab scientists in the Ebola response are valued contributors to ending this epidemic.

Based on what was learned during the lab science and safety reviews earlier this year, CDC has taken several immediate actions in this incident including closure of the laboratory, notification of staff, initiation of a complete internal review, and notifications of regulatory oversight agencies. This review will give us a clear understanding of what happened in this case and what can be done to further improve laboratory safety.

CDC has established a CDC-wide single point of accountability for laboratory science and safety and this will aid in ensuring accountability in this situation.

CDC will also report this event to its external advisory committee which provides ongoing advice and direction for laboratory science and safety.

One person--the BSL-2 lab technician who processed the material and who currently has no symptoms of illness--has been assessed and will be monitored for 21 days, according to CDC guidance. Others who entered the lab have been contacted and were assessed for possible exposure. As of this time we believe exposure requiring monitoring is limited to one individual.

http://www.cdc.gov/media/presskit.html

 

[Pathfinder]

CDC Worker 'Remains Well' After Possible Ebola Exposure at Lab

A CDC technician "remains well" and continues to be monitored for symptoms after the employee was potentially exposed to the Ebola virus during a mistake this week at an agency biocontainment lab in Atlanta, a CDC spokeswoman said Friday. The health risk to the worker is "deemed low," so the technician has not been required to be isolated and is not facing "other restrictions," said CDC spokeswoman Barbara Reynolds. The monitoring of that employee will span 21 days.
...

http://www.nbcnews.com/storyline/eb...ell-after-possible-ebola-exposure-lab-n275326

 

[Pathfinder]

CDC worker possibly exposed to Ebola in mishap shows no signs of disease: U.S. official

WASHINGTON Sun Dec 28, 2014 1:04pm EST

(Reuters) - The laboratory technician who may have been exposed to Ebola in a mishap last week at the Centers for Disease Control and Prevention in Atlanta is showing no signs of the disease, the U.S. Ebola coordinator said on Sunday.

"Only one technician was exposed. So far she's showing no signs of having the disease. She's being monitored every day," Ron Klain, named by President Barack Obama in October to lead the U.S. response to Ebola, told CBS's "Face the Nation".
...
Klain called the mishap "unacceptable" and said CDC Director Dr. Tom Frieden had promised a report in four weeks on the investigation into the incident.
...

http://www.reuters.com/article/2014/12/28/us-health-ebola-usa-idUSKBN0K60HX20141228

 

[Pathfinder]

Exclusive: CDC to hire lab safety chief after Ebola, bird flu mishaps

By Julie Steenhuysen
CHICAGO Wed Dec 31, 2014 1:07am EST

(Reuters) - The U.S. Centers for Disease Control and Prevention plans to hire a chief of laboratory safety, a new post that has taken on more urgency after a CDC scientist was possibly exposed to Ebola in a laboratory last week.

Creating a new high-level safety position was a key recommendation of a months-long internal investigation into the mishandling of anthrax and bird flu in CDC labs this past summer, according to an internal CDC memo obtained by Reuters.
...
Filling the new position, though, may seem too little, too late for at least one lab worker, who last week may have been exposed to live Ebola while working in a CDC laboratory in Atlanta.
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The CDC said on Tuesday the scientist was not showing symptoms and had a "low, but not zero, risk" of contracting Ebola
...

http://www.reuters.com/article/2014/...0K908E20141231

 

[Pathfinder]

U.S. lab worker possibly exposed to Ebola showing no symptoms: CDC

CHICAGO Fri Jan 9, 2015 2:29pm EST

(Reuters) - A scientist who may have accidentally been exposed to the deadly Ebola virus last month while working in a lab at the U.S. Centers for Disease Control and Prevention in Atlanta is showing no signs of the illness, the agency's director said on Friday.

CDC Director Dr. Thomas Frieden said in a conference call that the agency is still investigating the apparent mix-up that occurred Dec. 22...

...Frieden said the CDC will issue a report on the incident by the end of the month.

...

http://www.reuters.com/article/2015/01/09/us-health-ebola-usa-cdc-idUSKBN0KI21220150109

 

[Pathfinder]

CDC Releases Report on Recent Lab Incident

CDC review shows unlikely exposure, makes recommendations for continued safety improvements

Media Statement

For Immediate Release: Wednesday, February 4, 2015
Contact: Media Relations, Office of Communication
(404) 639-3286

The Centers for Disease Control and Prevention (CDC) has completed an internal investigation of an incident that occurred in December within the agency’s Ebola virus laboratory, which resulted in no illness and was unlikely to have involved an exposure to live Ebola virus. CDC’s investigation found that this laboratory incident occurred for two main reasons related to inadequate safeguards: 1) lack of a written study plan that had been approved by a supervisor; and 2) a study plan workflow that was not designed to sufficiently minimize the possibility that human error could result in potential exposure. CDC had already taken many steps to improve safety and will take additional steps as a result of this review.

In December, CDC reported that a small amount of material from an experiment that was part of an Ebola virus study was securely transported from a select‐agent‐approved BSL‐4 lab to a select‐agent‐approved BSL‐2 lab and may have contained live virus. The material mistakenly transferred during procedures for this study was on a sealed plate but should not have been moved from the BSL-4 laboratory into the BSL‐2 laboratory. The study involved scientists placing identical oral swab samples from guinea pigs into two sets of tubes—one set of tubes for live virus studies and one set of tubes for studies with inactivated material. The tubes were identical in brand and size and only differentiated by color caps and labels. Appropriate and approved inactivation procedures, consistent with recently implemented laboratory safety improvements, were used. Unfortunately, however, human error resulted in the swabs being placed into tubes in such a way that another technician mistakenly transported the wrong specimens to the BSL-2 lab.

The report also describes two previous recommendations that had not yet been fully implemented in this lab that could potentially have reduced the likelihood of this incident: 1) installation of a camera system for secondary verification of critical safety control points; and 2) proper use of a required Material Transfer Certificate (MTC) form for materials taken out of CDC’s high containment laboratories to lower biosafety level laboratories, including internal transfers.

CDC’s investigation found that immediate steps were taken to minimize any risk to CDC lab staff and that this incident was reported to appropriate authorities in a timely manner. In addition, the involved BSL-4 lab has suspended transfers out of the lab until a full review of the incident is completed and appropriate improvements are initiated. CDC is currently installing camera systems in the BSL-4 laboratory and providing clear instructions on the intended use of the MTC form prior to resuming full BSL-4 operations.

The laboratory technician who worked directly with the specimens in the BSL-2 laboratory completed 21 days of direct active monitoring and reported no illness consistent with Ebola. The agency performed additional laboratory studies on swabs taken the workdays before and after the incident which found it was unlikely that the specimens transferred to the BSL-2 laboratory contained live Ebola virus. Although the studies determined there was no safety risk to CDC staff or the public, CDC will ensure continuous improvements occur to protect the safety of CDC staff and the broader community.
Among steps CDC is taking or has taken to address this incident:

• Enhance standard operating procedures for materials intended for inactivation and removal from laboratories to ensure that
  • All materials are in standard, appropriately labeled, easily distinguishable tubes.
  • Multiple, redundant visual safeguards are used.

• Ensure CDC scientists have a full understanding of previously recommended laboratory safety improvements, including required use of the MTC form, and that they implement them.
• Work with CDC scientists from high containment laboratories to establish a peer-review system of written research plans to foster critical thinking on how to optimize workflows in protocols and minimize error.

While the incident described in this report highlights the need for continued enhancements to laboratory safety practices across the agency, CDC has made progress in this area over the past several months. Examples include:

• Established and recruiting for a new position, the Associate Director for Laboratory Science and Safety, with responsibility for providing agency-wide leadership and accountability for laboratory science, safety, and quality.
• Worked with laboratory staff and laboratory leadership to identify other safety improvement measures, including expansion of biosafety training and improvements in research standards and protocols.
• Undertaken an inventory of all stored biologic materials.
• Formed an external laboratory safety working group, under the Advisory Committee to the Director, composed of experts in biosafety and related areas to review and provide input into corrective actions and safeguards across all CDC laboratories.

CDC leaders have expressed their disappointment and have repeatedly stressed the importance of minimizing any potential risk to staff. CDC’s efforts to improve lab safety are essential—with the safety of employees as the highest priority. The expertise and world-class knowledge that CDC scientists bring to laboratory work is vital and, while lab work will always carry some risk, it is crucial to saving lives and preventing disease. CDC is committed to ongoing efforts to identify and implement systems and procedures that will allow the agency to provide maximum protections for laboratory staff and the broader community while conducting its critical laboratory work.

Link to CDC’s laboratory safety site for the full report

http://www.cdc.gov/media/releases/20...ebola-lab.html


Full report:

• 2/4/15: Report on the Potential Exposure to Ebola Virus[566KB]